High Prevalence of Dysmorphic Uterus in an Infertile Population Using 3D-TVUS and CUME Criteria: A Retrospective Cohort Study

Background: The true prevalence and clinical impact of congenital uterine malformations (CMU), particularly the dysmorphic uterus, in infertile populations remain debated, largely due to historical diagnostic limitations. This study aimed to determine the prevalence of CMU in an infertile cohort using modern, objective 3D transvaginal ultrasound (3D-TVUS) criteria and to evaluate reproductive outcomes following surgical correction. Methods: This retrospective cohort study included 154 women presenting for infertility investigation at a university hospital tertiary referral center between January 2020 and December 2022. All patients underwent 3D-TVUS for uterine assessment based on Congenital Uterine Malformation by Experts (CUME) criteria. Women diagnosed with CMU underwent hysteroscopic metroplasty. The primary outcomes were the prevalence of CMU subtypes and the 1-year cumulative live birth rate (LBR). Statistical analysis was performed using one-way ANOVA and chi-square tests. Results: CMU was identified in 47/154 (30.5%) women. Dysmorphic uterus was the most common anomaly, present in 42/154 women (27.3% of the total cohort; 89.4% of all anomalies). A significant association was found between dysmorphic/septate uteri and the presence of endometrial polyps (45.2%/40.0% vs 8.5% in normal uteri; P<0.001). After metroplasty, the 1-year cumulative LBR for the dysmorphic uterus group (26.2%) was comparable to the normal uterus group (20.6%; P=0.907). The miscarriage rate per clinical pregnancy was also similar between the dysmorphic (15.4%) and normal uterus (25.7%) groups. Conclusions: The prevalence of dysmorphic uterus in infertile women is substantially higher than previously understood when assessed with modern, objective 3D-TVUS criteria. Surgical correction appears to normalize reproductive outcomes to levels seen in infertile women with normal uteri. The novel association with endometrial polyps warrants further investigation and reinforces the utility of comprehensive uterine assessment in the infertility workup.